43698_JACKSON, RHODA_20060120

i' iCAMA / _! DREDGE & FILL
GENERAL PERMIT Previous permit#
❑New [ Modification J Complete Reissue ❑Partial Reissue Date previous permit issued
As authorized by the State of North Carolina, Department of Environment and Natural Resources
and the Coastal Resources Commission in an area of environmental concern pursuant to I SA NCAC
❑ Rules attached.
Applicant Name` '
Address
City___ *'-' r^ State ZIP
Phone # (_ ) Fax # (---)
Authorized Agent _
Affected CW J EW J PTA ES ❑ PTS
AEC(s): _I OEA HHF IH UBA ❑ N/A
J PWS: -J FC:
ORW: yes / no PNA yes / no Crit. Hab. yes / no
Type of Project/ Activity
Pier (dock) length _
Platform(s)
Finger pier(s)
Groin length -
number
Bulkhead/ Riprap length__
avg distance offshore
max distance offshore
Basin, channel
cubic yards
Boat ramp _
Boathouse/ Boatlift
Beach Bulldozing
Other
-------------
Shoreline Length
Project Location: County
Street Address/ State Road/ Lot #(s)
Subdivision
City_ - _ _ ZIP
Phone # (_ _ _) /'7 f River Basin
Adj. Wtr. Bodyy( --t (: { ' ' f (nat tman lunknl
Closest Maj. Wtr. Body _
(Scale: )
SAV: not sure yes no _.. — - - — ---- -
Sandbags: not sure yes n
Moratorium: n/a yes /no
Photos: yes i
Waiver Attached: yes `rio
A building permit may be required by: ( See note on back regarding River Basin rules.
Notes/ Special Conditions
Agent or Applicant Printed Name
Signature Please read compliance statement on back of permit
UO
Application Fee(s) Check #
Permii Officer's Signature
W '
Issuing Da Expiration Date
-
j.
Local Planning Jurisdiction Rover File Name

Statement of Compliance and Consistency
This permit is subject to compliance with this application, site drawing and attached general and specific conditions. Any
violation of these terms may subject the permittee to a fine or criminal or civil action; and may cause the permit to become
null and void.
This permit must be on the project site and accessible to the permit officer when the project is inspected for compliance. The
applicant certifies by signing this permit that 1) prior to undertaking any activities authorized by this permit, the applicant will
confer with appropriate local authorities to confirm that this project is consistent with the local land use plan and all local
ordinances, and 2) a written statement or certified mail return receipt has been obtained from the adjacent riparian
landowners).
The State of North Carolina and the Division of Coastal Management, in issuing this permit under the best available
information and belief, certify thatthis project is consistent with the North Carolina Coastal Management Program.
River Basin Rules Applicable To Your Project:
❑ Tar - Pamlico River Basin Buffer Rules ❑ Other:
❑ Neuse River Basin Buffer Rules
If indicated on front of permit, your project is subject to the Environmental Management Commission's Buffer Rules for the
River Basin checked above due to its location within that River Basin. These buffer rules are enforced by the NC Division of
Water Quality. Contact the Division of Water Quality at the Washington Regional Office (252-946-6481) or the Wilmington
Regional Office (910-796-7215) for more information on how to comply with these buffer rules.
Division of Coastal Management Offices
Central Office
Mailing Address:
1638 Mail Service Center
Raleigh, NC 27699-1638
Location:
Parker -Lincoln Building
2728 Capital Blvd.
Raleigh, NC 27604
919-733-2293
Fax: [phone]
Elizabeth City District
1367 U.S. 17 South
Elizabeth City, NC 27909
252-264-3901
Fax: [phone]
(Serves: Camden, Chowan, Currituck,
Dare, Gates, Pasquotank and Perquimans
Counties)
Morehead City District
400 Commerce Ave
Morehead City, NC 28557
202-808-2808/ 1-888-4RCOAST
Fax: [phone]
(Serves: Carteret, Craven, Onslow -above
New River Inlet- and Pamlico Counties)
Washington District
943 Washington Square Mall
Washington, NC 27889
252-946-6481
Fax: [phone]
(Serves: Beaufort, Bertie, Hertford, Hyde,
Tyrrell and Washington Counties)
Wilmington District
127 Cardinal Drive Ext.
Wilmington, NC 28405-3845
910-796-7215
Fax: [phone]
(Serves: Brunswick, New Hanover,
Onslow -below New River Inlet- and
Pender Counties)
Revised 06/29/05

DIVISION OF COASTAL MANAGEMENT
ADJACENT RIPARIAN PROPERTY OWNER NOTIFICATION/WAIVER FORM
Name. of Individual applying for' Permit:
K-h f�r� hackie, 3+ 61. t'�`
Address of Pro ert 1Z, i.13i11tl1 �JI.U�ASI �,�
N C✓ 2<bs
C o fACW COAf4t
(Lot or Street #, Street or Road, City & County)
I hereby certify that I own property adjacent to the above referenced property. The individual
applying for this permit has described to me as shown on the attached dravdng the development
they are proposing. A description or drawing, with dimensions, should be provided with this
letter.
—1xv— I have no objections to this proposal.
If you have objections to what is being proposed, please write the Division of Coastal
Afanagement, Hestron Plaza XI, 151-8, Hwy. 24, Morehead City, NC, 285=7 or call (252) 808-
a808 within 10 days of receipt of this notice. 'V4 response is considered the s12me as no objection
if you have been notified by Certified Mail.
WAIVER SECTION
I understand that a pier, dock, mooring pilings, breakwater, boat house, lift or sandbags must be
set back a minimum distance of t 5' from my area of riparian access unless «waived by me. (If you
wish*ttoo waive the setback, you must initial the appropriate blank below.)
1" W'�i do wish to waive the l5' setback requirement.
Si.inature
1 do not wish to waive the i 5' setback requirement.
Date
Print Name "
Telephone Number With Area Code
AUG 31,2005 09:40
Page 2

�` ��sa� �33-says

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TY 0 WNJ,�'R STAIT
AD ACENTRi.-MiUAN !�,,')r
EMWENr
. . . . . . . . . . . . . x
(FOR A PIERIUNCO VERED B011 7'111n)
I hereby certify that f own property adjacent to
P"s.
(N.-III! 1 e of Prope rt Y 0 w u e r)
property located at
(Lot, Block, Road, etc.)
on in
(Waterbody)
(Town and/orl County)
He has described to me, as shown below, the dev--!opment he is proposing at that
Icc-ation, and, I have no objections to his, proposal. I undersuand 0lat a pier/uncovered boat lift
must be s4c,, '�ack a minimum distance of ififtten fe--c 15') from my area or nd paan access unless
'
waived by me.
I do not wish to waive the sc�ack requirement.
se
I do wish to waive that setback requirement.
-------- -------------------------- ------------- r ---------------------------------
---------------- — ------------------
DESCRIMON /OR DRAW-RiG OF PROPOS
AND
ED: D E V E L 0 P-NLF—N-T
(To be flUed in by indjv&u-4-j de'rellIpment)
Sigr,,aturc
Print or Type N;vne
Telephone Nufllbtr
Date: —A
A

©1*19 KIR: COMPLETE THIS SECTION
` ■ Complete items 1, 2, and 3. Also complete
` item 4 if Restricted Delivery is desired.
` ■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
A. lirignatur
X ✓ ❑ Agent
❑ Addressee
B. Receiv d by ( Printed NJare) C. Date of Delivery
D. Is delivery address different from item 17 ❑ Yes
If YES, enter delivery address below: ❑ No
3. ServiceType
ertified Mail ❑ Express Mail
❑ Registered ❑ Return Receipt for Merchandise
❑ Insured Mail ❑ C.O.D.
4. Restricted Delivery? (Extra Fee) ❑ Yes
2. Article Number
(transfer from service label) 7005 1160 0003 1594 5456
PS Form 3811, February 2004 Domestic Return Receipt 102595-02-M-1540

UNITED STATES POSTAL SERVICE
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •

6
-M�R: COMPLETE THIS SECTION
■ Complete items 1, 2, and 3. Also complete
item 4 if Restricted Delivery is desired.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
-To +he- -Vxa-pc�y of-xnecs c�
moo W ict Qn V- -Dr-,
A. Si nature
X 6l% _ ❑Agent
essee
B. Received y ( Printed Name) C. Pate of Del'v
93s'yy t4
D. Is delivery address r&erent from item 1? ❑ Yes
If YES, enter delivery address below: No
3.
-13 in
4. ffesA
Mail ❑ Express Mail
led ❑ Return Receipt for Merchandise
Mail ❑ C.O.D.
2. Article Number — -
(Transfer from service label) 7 0 0 5
PS Form 3811, February 2004 Domestic ReturmIJaWW,,�
,ery? (Extra Fee) ❑ Yes
1594 5463
102595-02-M-1540

UNITED STATES POSTAL SERVICE
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
• Sender: Please print your name, address, and ZIP+4 in this box •

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